Provider Demographics
NPI:1184813172
Name:NORTHERN VIRGINIA VISION CENTER, INC.
Entity type:Organization
Organization Name:NORTHERN VIRGINIA VISION CENTER, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:AYMAN
Authorized Official - Middle Name:
Authorized Official - Last Name:BOUTROS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:703-573-8080
Mailing Address - Street 1:8316 ARLINGTON BLVD
Mailing Address - Street 2:SUITE 235
Mailing Address - City:FAIRFAX
Mailing Address - State:VA
Mailing Address - Zip Code:22031-5207
Mailing Address - Country:US
Mailing Address - Phone:703-573-8080
Mailing Address - Fax:703-573-2929
Practice Address - Street 1:8316 ARLINGTON BLVD
Practice Address - Street 2:SUITE 235
Practice Address - City:FAIRFAX
Practice Address - State:VA
Practice Address - Zip Code:22031-5207
Practice Address - Country:US
Practice Address - Phone:703-573-8080
Practice Address - Fax:703-573-2929
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-16
Last Update Date:2007-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101043806207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV95149000Medicaid
WV9639000Medicaid
WV95149000Medicaid
VA014993N63Medicare PIN
VA000C42N63Medicare PIN
VA004641N82Medicare PIN
VA000C43N63Medicare PIN
VA0858550003Medicare PIN